Knowledge of HPV and HPV Vaccination among Polish Students from Medical and Non-Medical Universities

Human papillomavirus (HPV) is a common sexually transmitted infection that can cause both benign and malignant lesions. HPV vaccines, preferably administered before the onset of sexual activity, have demonstrated remarkable efficacy in preventing HPV-related cancers. The impact of a healthcare provider’s recommendation on HPV vaccine acceptance is substantial. Therefore, medical students must undergo thorough training in this domain. This study compares fundamental understanding and viewpoints regarding HPV and anti-HPV vaccines among Polish students pursuing medical and non-medical sciences. This study was based on the authors’ questionnaire, and the results were statistically analyzed. The participants in this study were 1025 students (medical sciences students—520 respondents in total; and non-medical sciences students—505 respondents in total). According to the results, medical students’ knowledge about the consequences of HPV infection and vaccination against HPV was significantly greater. To date, numerous publications have investigated the understanding of particular social, gender, parental, etc., groups about vaccination, but the knowledge of students at different universities—medical and other—has not been compared. Social awareness is still insufficient, even in groups of medical students. There is much to be done to educate and encourage preventive behavior in those not receiving primary prevention in early childhood.

The most effective means of preventing cervical cancer (cc) is using anti-HPV vaccines.Vaccines protect primarily by stimulating antibody production by the immune system.HPV vaccines use virus-like particles (VLPs) that contain elements from the HPV virus's surface.VLPs do not have viral DNA; therefore, they are not infectious or carcinogenic but closely resemble the natural virus.Antibodies that respond to VLPs also provide immunity against the virus [7,8].
Currently, there are three HPV prophylactic vaccines available commercially in Europe: Gardasil ® 4 (quadrivalent vaccine against HPV 16,18,6,and 11; available from 2006), Cervarix™ (bivalent vaccine against HPV 16 and 18; approved by the EMA in 2007 and FDA in 2009), and Gardasil ® 9 (nonavalent vaccine against HPV 6,11,16,18,31,33, 45, 52, and 58; available from 2014) [9].Recommended vaccination schedules include two doses for boys and girls between 9 and 14 and three doses for those 15 years or older.The decision about which type of vaccine to use should be made on an individual basis [9,10].However, in April 2020, the WHO Strategic Advisory Group of Experts on Immunization (SAGE) reviewed evidence indicating that one-or two-dose schedules are as effective as three.The WHO's recommendations will be revised after receiving feedback from all the stakeholders [11].
Anti-HPV vaccines have been shown to decrease the risk of HPV-associated lesions, including cervical intraepithelial neoplasia (CIN), genital warts, anal neoplasia, and recurrent respiratory papillomatosis (RRP); they are often used to lower the chance of disease recurrence [12,13].There is also evidence that they reduce the risk of the recurrence of highgrade squamous intraepithelial lesions (CIN2+, which means HSIL-CIN 2 + CIN 3 + small invasive cervical cancer), especially in cases involving HPV16 or HPV18, in women who have undergone local excision by administering the vaccine after treatment [14,15].
Research has presented substantial proof that anti-HPV vaccines have played a crucial role in decreasing the incidence of cervical cancer as a significant health concern [16].By 2030, the World Health Organization aims to ensure that 90% of girls are fully vaccinated by the time they reach the age of 15.Cervical cancer affects many women, with around 570,000 cases and 311,000 deaths occurring yearly.This disease is particularly prevalent in low-and lower-middle-income countries, making it difficult to eliminate [17,18].Australia is a prime example of a country implementing a nationwide HPV vaccination program, as it did so in 2007 for girls and five years later for boys.As a result, Australia is on a path to eradicate cervical cancer in the next 20 years, with fewer than four new cases per 100,000 women each year by 2028.Other high-income countries that have successfully reduced the number of HPV-related cancers are the United Kingdom, New Zealand, and Sweden [19][20][21].Vaccine hesitancy remains a significant issue in European countries despite the implementation of various programs.Developing informational campaigns and encouraging healthcare professionals to be open to listening and discussing vaccine concerns with patients is crucial [22,23].
This study aims to compare fundamental understanding and viewpoints regarding HPV and anti-HPV vaccines among Polish students pursuing medical and non-medical sciences.We aim to identify the differences in knowledge and opinions between the two groups and genders.The findings from this study can shed light on any gaps in knowledge and highlight the need for modifying the approach to educating and disseminating information within the academic setting.

Study Design and Participants
The study was carried out between 1 June and 31 July 2023.The Bioethics Committee approved it at the Pozna ń University of Medical Sciences (540/22), and the survey was based on the authors' questionnaire.In the study, 1025 students (655 women, 361 men, and 9 participants who did not state their gender) at Polish universities completed the questionnaire voluntarily.Participants were divided into two groups: medical sciences students-520 respondents in total; and non-medical sciences students-505 respondents.
This study originally included 1033 students, but all the questionnaires that were completed incorrectly or contained incomplete data were eliminated from the study and were not included in the statistical analysis.

Questionnaire
A questionnaire was designed specifically for this study by the authors.The survey consisted of 28 questions: 24 were closed, comprising 20 single-choice questions and 4 multiple-choice questions; 4 were semi-open, comprising 2 single-choice questions and 2 multiple-choice questions; 3 were open.The first part of the questionnaire included questions about gender, age, the city of the study, the name of the university, and a question differentiating medical and non-medical sciences students.The second part of the questionnaire consisted of questions referring to the student's knowledge about HPV and HPV vaccination and their vaccination status.The last part of the questionnaire included questions about public health associated with HPV vaccination.
The survey was sent via Google Forms and shared on social media and fora at various universities in Poland.In the introduction to the questionnaire, the respondents were assured that their participation in the survey was completely voluntary and that it was anonymous.If the respondents indicated permanent contraindications to vaccination, the following were considered: an anaphylactic reaction to a previous dose or an allergy to any part of the vaccine.

Statistical Analysis
Statistical analysis was developed using R software (version R4.1.2).The characteristics of the responses to individual categorical questions were summarized with regard to their number and percentage share in the group.To characterize the age of the responders, we used basic descriptive statistics (mean, standard deviation, median, interquartile range, minimum value, and maximum value).Comparisons between medical students and other respondents were made using Pearson's Chi-square test or Fisher's exact test, depending on the condition of the expected number of observations.All the statistical calculations assumed α = 0.05.

Results
In the survey, 1025 volunteers participated, of whom 655 (63.9%) were women and 361 (35.2%) were men.Nine subjects did not want to disclose their gender.The demographic data of the respondents are presented in Table 1.Half of the respondents were students at medical universities (50.7%), and the rest were students at other non-medical universities in Poland (49.3%).
When asked about the possible transmission of infection with human papillomavirus, 972/1025 (94.8%) unanimously answered that it was sexual.Less than half of the respondents knew that HPV can cause cancer of the oropharynx or anal cancer (47.9% and 43.8%, respectively).Regarding knowledge about prophylaxis, 853 subjects-which is 83.2% of the study group-had heard of HPV vaccination.To the question "What HPV vaccination is recommended?",33.7% answered "I do not know", and 16.8% did not respond.Out of all the respondents, 314 (30.6%) declared that they were vaccinated against HPV, 539 (52.6%) said they were not vaccinated, and 172 people did not answer.Arguments supporting the decision not to vaccinate and their percentage distribution (multiple answers possible) are presented in Table 2.
Table 3 presents the respondents' answers divided into fields of study-medical and non-medical.To the question, "How many types of HPV are there?",57.5% of the medical group answered that there were about 200 types, and another 24.8% answered that there were a dozen, which is a significant difference (p < 0.001) compared to the non-medical group (10.7% and 16.2%, respectively).To the question "What is the route of HPV transmission?",both groups most often marked the answer "sexual"-97.7%from the medical group and 91.9% from the non-medical group (p < 0.001).Significantly more often, people from the non-medical group also marked the answer "by blood"-38% compared to 22.7% from the medical group.Statistical significance also concerned vertical transmission during labor and droplet transmission.According to the results, medical students' knowledge about the consequences of HPV infection was significantly greater.Almost the entire medical group (98.8%) marked the answer "cervical cancer", whereas 70.3% (p < 0.001) marked this answer in the nonmedical group.Indeed, fewer non-medical students marked the answer "oropharyngeal cancer"-22.2%(non-medical group) vs. 72.9%(medical group)-or "anal cancer"-21.6%(non-medical group) vs. 65.4% (medical group).Despite significant differences in the results among the groups, the low awareness of the medical group about the consequences of persistent, long-term infection with oncogenic HPV genotypes is noteworthy.In the medical group, 74.2% answered "condylomas", 40%-"smelly discharge, pelvic pain", 39.8%-"bleeding after intercourse", and 37.1%-"hoarseness, cough".Knowledge about the possibility of preventing primary infection varied significantly between the groups of the respondents (91.7% of the medical group believed it was preventable, whereas 68.5% of the non-medical group believed it was preventable).Responses about the cervical cancer prevention program in Poland (85.5% vs. 61.6%)and HPV vaccination (98.3% vs. 67.7%)were similar.Of noteworthy interest is the high percentage of responses among medical students regarding the value of vaccination after starting intercourse (84.4%) and recommending vaccination in men (79.2%).The question "Do you find vaccination against HPV safe?" shows a significant gap in social consciousness.Only half of the non-medical student group agreed with this notion (50.3%), and 91.9% of the medical student group supported it (p < 0.001).One should also pay attention to the low rates of vaccination among Polish young people-only 38.7% of the medical students were vaccinated, and the percentage was 22.4% in the non-medical group.The answer to the question "Do you recommend HPV vaccination for your loved ones and/or children in the future?"divided the study group-91.5% of the medical ones recommended it, and in the non-medical group-only 50.3% recommended it.

Discussion
Our study compared the fundamental understanding and viewpoints regarding HPV and vaccines against HPV among two groups of Polish students studying medical and nonmedical sciences.We aimed to identify the differences in knowledge and opinions between the groups.The findings from this study can shed light on any gaps in knowledge and highlight the need for modifying the approach to educating and disseminating information within an academic setting.
The answers provided highlight the need to conduct social and promotional campaigns addressed to young adults.This is because this is the age group both starting sexual activity and being the most active in this regard, thus being the most exposed to fresh HPV infections.The respondents also stressed the need to better communicate information about HPV vaccination among young people.They believed that the introduction of a cervical cancer prevention program was an essential element in the fight against HPV-related diseases.Perhaps greater social awareness, not only among groups related to medical professions, could contribute to a greater willingness to vaccinate oneself, one's children, and other family members in the future.It is for this reason that we emphasize the value of social campaigns addressed to people caring for children-parents, teachers, and tutors.
So far, there had been numerous publications describing the knowledge of particular social, gender, parental, etc. groups about vaccination, but the knowledge of students at different universities-medical and other-had not been compared prior.
Bednarczyk R., in his study, attempted to explain five myths about HPV vaccination and explain why there was such a low level of knowledge in society in general.He highlighted the fact that, five years ago, the utilization rates for a single dose of the HPV vaccine and the completion of the HPV vaccine series were 66% and 49%, respectively.This contrasts with the adoption rates of the tetanus, diphtheria, and acellular pertussis vaccines (89%) as well as the quadrivalent meningococcal conjugate vaccine (85%).Five prevalent misconceptions were addressed, including the beliefs that HPV vaccination lacked effectiveness in preventing cancer, Pap smears alone were adequate for cervical cancer prevention, HPV vaccination posed safety concerns, HPV vaccination was unnecessary because the immune system naturally clears most infections, and vaccinating at 11-12 years of age was too early [24].
The results of this review from 2020 were worse than the results we received.Still, they showed the factors that conditioned disproportions in knowledge about HPV and the willingness to get vaccinated.This study's findings indicate a lack of comprehensive adolescent knowledge regarding HPV and its preventive vaccine.Adolescents tend to underestimate their susceptibility to HPV infections.To enhance their understanding of HPV and its implications, researchers suggest that information be disseminated through compulsory schooling, primary healthcare channels, and the creation of interactive and informative interventions.The limited understanding and perceived vulnerability observed among adolescents towards HPV infection and related illnesses underscore the urgency of a well-crafted training program aimed at bridging the information gap concerning the HPV virus and promoting the acceptance of the HPV vaccine [25].A similar study was conducted by Zhang et al. in the Chinese population [26], and, two years ago, scientists from Poland presented the results of an extensive analysis conducted on the knowledge of medical and dental students.They found that 259 (24.41%) of the 1061 medical students were vaccinated against HPV.A notable enhancement in overall knowledge during the later years of education (4-6) was delineated in contrast to the early years (1-3).
Nevertheless, it was shown that, despite advancements in medical education, substantial knowledge gaps persist regarding the connection between HPV infection and HPV-related lesions.We also share these conclusions, although it is worth noting that the vaccination coverage of Polish students in medical schools increased from 24.4 to 38.7%, which is very optimistic [27].Another interesting study worth mentioning is the testing of knowledge among people closely related to gynecology, including gynecology and obstetrics residents, and this study was undertaken via research conducted by the International Society for the Vulvovaginal Diseases (ISSVD) [28].Such studies are not comparative among the populations studied but provide a picture of knowledge about rarer diseases.Among other similar studies, other interesting ones focus on knowledge about HPV-among nursing students from Turkey [29] and non-medical students from India or Alabama [30,31].The former study (the cross-section study among nursing and midwifery students in Turkey) revealed that both nursing and midwifery students knew little about HPV, even when divided into groups.More considerable awareness was observed in midwifery students than in nursing.Additional analysis showed significantly higher knowledge in women than in men, which may probably be due to the belief that HPVrelated diseases only affect women.In the past, it was believed that only girls should be vaccinated.However, current standards and increasing social awareness have contributed to an increase in the vaccination rate in society.

Table 1 .
Characteristics of the study group.
SD is the standard deviation, and IQR is the interquartile range.* n = 652.

Table 2 .
Vaccination against HPV in the study group.
* n = 539.The total exceeded 100% due to the possibility of selecting more than one answer.

Table 3 .
Comparison of answers regarding HPV vaccinations between the medical and non-medical groups.

Table 3 .
Cont.Data are presented as a number of observations (% of the group).Comparisons between medical students and other respondents were made using the Pearson Chi-square test or Fisher's exact test1.* The total exceeded 100% due to the possibility of selecting more than one answer.